Case discussion: How would you treat this patient? [6 August]

This week we have an engaging case. From the shown clinical and dermoscopy images, please evaluate, indicate your likely diagnosis, and method of biopsy.

Case discussion      Case discussion

Update:

These are the results from the pathology report. What is your conclusion and what are the next steps you would take to treat this patient?

Case discussion

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14 comments on “Case discussion: How would you treat this patient? [6 August]

  1. A nodular lesion with serpentine vessels, keratin and erosion ( 12 o’clock???)…
    Looks like BCC but, the keratin scales don’t fit the diagnosis of BCC….could be invasive SCC….
    I would surgically excise the lesion for diagnosis…

  2. The arborising vessels give the impression of BCC but rest of the lesion doesn`t match up. This might be amelanotic melanoma, or a more rare pink nodular tumor as atypical fibroxanthoma,sebaceous carcinoma… Diagnosis will need histopathology : excise with narrow margins.

  3. Clinically a nodular, ulcerated, amelanotic lesion with arborising blood vessels. Will need a wide excision. DDx: Amelanotic melamona, BCC, scc in that order.

  4. This lesion is either an AMM or BCC. I would excise it with a 2mm margin to get a histological diagnosis and go from there.

  5. Not melanocytic arborising vessels ulceration DD BCC SCC other malignant Would biopsy punch or shave

  6. pink ill defined nodule, no history of how long this has been there; vessels serpentine, branched, with possibly some dot and linear vessels at 4-10 o’clock; quite a bit of white, with some white lines 4-5 o’clock and white structureless centrally; some ulceration, some scale; not sure whether this is a BCC or SCC; could also be amelanotic melanoma; excise with a 2mm margin and palpate the local lymph nodes;

    Question for David:

    If you excise with a 2mm margin and it is an SCC, would you go back and take more margin?

    Thanks, Bronwyn.

  7. Pink nodular lesion with arborising vessels, ulceration noted. Ddx: modular BCC, amelanocytic melanoma. Will excise at 2 mm margin and further management based on histology confirmation.

  8. Lesion without pigment
    pink
    raised
    white structures
    scales
    paler lower left
    Vessels
    Radial
    Branching
    Serpentine
    Looped
    coiled
    Dotted vessels not seen
    Diagnosis
    Infiltrative SCC (KA/BCC in DD)
    Management
    Assessment of nodes + full skin check
    6 mm dermoscopic excision margin

  9. like most of you, I thought this was a BCC, but also that it looked a bit odd. I always do a biopsy first, and so I would have done a 3 or 4mm punch. With a confirmed BCC I would then excise with 4mm margins. For me, I (almost) always punch pink lesions, and I (almost) always get a diagnosis before I treat. My practice is always to biopsy on the day, at the time of consultation, do results by phone (almost always) and then excise at a scheduled time. To answer Bronwyn – 2mm margins is not enough for most SCC, and that is why I would do a partial (punch) biopsy first.

  10. nodular BCC – branching vessels,
    some scale at the lesion – may be mixed with Bowen’s disease
    Mx – excision with 2mm margin